Healthcare Value Analysis

Infection Prevention and Value Analysis Forge Even Stronger Relationships

By Barbara Strain, MA, CVAHP

Editor's note: This column originally appeared in the June 2021 issue of Healthcare Hygiene magazine.

Prior to 2020 the participation of infection prevention and control (IP&C) was a key element of successful value analysis (VA) initiatives, but the role took on even more significance because of the COVID-19 pandemic.1 SARS-CoV-2 was a novel virus in the most complete sense. It had not been previously isolated, its mode of transmission was not completely understood, nor were there laboratory tests to detect the presence of the virus itself nor testing for antibody levels to determine immune status. Hot spots were occurring with the rapid surge of symptomatic, sick, and dying patients in healthcare institutions around the world. It became obvious very quickly that there were competing challenges that effected all aspects of the path forward: staff safety, vetting, sourcing, and conserving supplies, and patient care.

To quote an IDN that was interviewed for an Association of Healthcare Value Analysis Professionals (AHVAP) podcast in May 2020, “ensuring the safety of the front-line staff” was essential. To stay abreast of the fast-changing CDC guidelines to assure the most appropriate personal protective equipment (PPE) was available to the clinical and support staff, infection preventionists (IPs) conducted real-time assessments of how care was being provided. It was quickly determined that the usual method of triage and assigning patients to open ICU beds was not an optimal model, so IP&C recommended cohorting patients and staff to dedicated ICUs as the best scenario.

In this newly created, dynamic care environment, staff could don gowns, masks and head coverings, and wear them for longer periods of time without removing, and, in some situations, donned coveralls over basic PPE to conserve use.

Each decision was made based on communication with value analysis professionals (VAPs) who are the clinical connection to hospital supply chain (SC) operations. Before practice was changed or procedures edited, IPs and VAPs conferred on availability of supplies to ensure that new plans could be carried out. SC would provide timely “run rates” indicating how fast high-demand supplies were being used and forecast how long current stock of supplies would last as well as when additional stock would arrive. Using their knowledge, skills, and abilities IPs and VAPs created lists of the key characteristics of the high-demand supplies which reduced the time to locate best-fit equivalents to ensure uninterrupted care.

When it became clear that the global supply of non-powered respirators/N95 masks were not keeping up with demand and were met with fit-testing constraints, the CDC decided to allow either third-party vendors to provide reprocessing services of these masks or allow hospitals to perform reprocessing on site by specific approved methodologies. VAPs gathered the information to determine which option(s) had the shortest implementation timeline for teams led by IPs along with staff from biomedical engineering and facilities, and executive leadership could make easy-to-operationalize, safe decisions.

Other conservation practices included IP&C approving the use of extra-long IV-intravenous tubing connected to the patient to allow respective IV pumps to function outside the room. This measure decreased the number of times a fully donned nurse had to go into a patient’s room to monitor and adjust the settings.

Even before it was confirmed by CDC and NIH that patients were highly contagious, IPs, chief medical officers and chief nursing officers instituted negative-pressure room policies. With the assistance of facilities management professionals, plans were put in place to convert regular patient rooms, emergency department holding rooms, and other appropriate care-spaces into negative-pressure conditions where physically possible. This kept contagious viral particles from entering non-care areas or areas where non-healthcare workers or those not wearing powered or non-powered N95 masks were present.

Prior to the availability of certain drugs, convalescent serum or other treatments were available for patients whose lung capacity and breathing conditions deteriorated, a large percentage were put on ventilators.2 In most hospitals there are fleet of ventilators for a normal level of patient need, plus a reserve amount for unexpected circumstances -- but it is not equipped to handle the high, long-lasting surge caused by COVID-19. VAPs were called into action to vet a new set of criteria for ventilator tubing and hoses as well as connectors for their own fleets of ventilators and for other models that may have been rented or purchased. Some hospitals that had both a space constraint and ventilator shortage adapted what the FDA referred to as “multiplexing ventilator tubing connectors, also known as ventilator splitters, in situations in which no alternatives for invasive ventilatory support are available,” and provide a considerations list that health care providers and facilities should review.3

In extreme situations, patients were placed on ECMO-extracorporeal membrane oxygenation treatment, where oxygen is delivered directly to the patient’s bloodstream to bring relief to breathing impairment. Hospitals with specially trained staff and ECMO equipment to support such treatments put additional strain on capacity to use this practice as patient demand rose above normal. Ventilators and ECMO come with their own set of issues that IP&C monitored closely along with anesthesiology and respiratory therapy to assure that precautions were in place to prevent development of ventilator-associated pneumonia, bloodstream and other infections.

Since the number of COVID-19 cases have ceded to lower, manageable levels, hospitals have begun to open their care services to pre-2020 conditions. Lessons learned from the pandemic informed how the delivery of care can be effective through:
· Reviewing and updating emergency operations, infection prevention and control, and institutional & departmental policies,
· Creating a response handbook based on critical triggers which include but are not limited to:
- Monitor CDC, WHO and other global health watchdogs by Emergency Preparedness Committees and IP&C
- Establish a global raw materials, work-in-progress and finished goods alert system and report dashboard
- List key departments – such as IP&C, VAP, SC -- who should be notified based on mutually agreed upon on-hand and available-to-purchase product thresholds
· Identifying top product needs in incident categories and develop a list of key characteristics for each product to facilitate quick decision-making. For example, for air born contagion: non-powered or powered respirators, face shields, protective gowns, oxygen masks/tubing, list of key characteristics each product type
· Adopting the communication style and methods that worked during Covid19 as your organization’s everyday method.

The COVID-19 pandemic has taught us many lessons but the importance of interprofessional relationships has been undeniably one of the best learned.

Barbara Strain, MA, CVAHP, is an independent healthcare value consultant whose clients range from new emerging and disruptive technology to Fortune 500 companies. Strain honed her expertise over a 40-year career as a healthcare provider across multiple specialties first in clinical laboratory operations, microbiology, disinfection and sterilization, and infection control, then as a value analysis professional. She is a founding member and past-president of the Association of Healthcare Value Analysis Professionals (AHVAP).

References:
1. https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/overview/index.html#IPC-priorities
2. https://www.npr.org/sections/health-shots/2020/04/02/826105278/ventilators-are-no-panacea-for-critically-ill-covid-19-patients
3. https://www.fda.gov/medical-devices/letters-health-care-providers/using-ventilator-splitters-during-covid-19-pandemic-letter-health-care-providers